Flatlined: Resuscitating American Medicine

Chapter 11. Unnecessary Surgery

In my clinic I repeatedly saw unfortunate patients whose stories precisely matched this fictional one. Jennifer Allen’s story helps explain why there is such a thing as unnecessary surgery. Back trouble ran in Jennifer’s family, and she first began having midline low back pain when she was thirty. After this episode physical therapy had helped; but because of two young children and the boring routine of regular exercise, she had not kept up with her therapy. Her back pain grew steadily worse with frequent flare-ups, and her family doctor ordered an MRI. When the report came back showing bulging, degenerated discs, the doctor referred Jennifer to Dr. Raymond Alford at the Episcopal Hospital. Alford had the reputation of being one of the best neurosurgeons in town. After briefly examining Jennifer and then reviewing the MRI in his office, he came back into the small examination room and said, “Jennifer, you have a degenerative condition in the discs in your back, and the vertebrae are causing pressure. You are going to have back pain until we relieve the pressure. We do this by fusing the spinal vertebrae, which will stop the movement in your back. The disc bulges are also exerting pressure on your nerves, and we will have to remove enough bone to get the pressure off the nerves.” Alford detailed the procedure: “We will place metal screws about the size of your little finger on both sides of three of your vertebrae. The 103 11 Unnecessary Surgery The filter for the application of new technology in the United States is ten doctors at Medicare’s headquarters in Baltimore and a scattered group of insurance doctors. CH011.qxd 10/7/08 10:01 AM Page 103 screws on each side will be connected by a rod so that nothing moves.” He showed her a plastic model of a normal spine, without the two pounds of hardware he would install, pointing with a pencil where each screw would go. “We will take bone from your hip and lay it over the vertebrae, and after about six months the bones will grow together. I think there is an 85 percent chance that your back pain will be much better, but there is a small chance you could be worse.” Jennifer considered the surgery for two weeks. Her condition did not sound good: pressure on nerves and degenerated discs. Finally, she called Alford’s office to schedule the procedure. Waking up after surgery, Jennifer knew that she had undergone a major operation. She was in agony; morphine barely took the edge off the pain. The next day she shuffled a few steps, wincing with each effort. After five days in the hospital she could feed herself, manage the bathroom, and circle the nurse’s station. Six months after the operation, Jennifer was still recovering. Even worse, the pain which had been intermittent before surgery was now constant . On her last visit to Dr. Alford, he dismissed her from care. Their relationship had become strained by her insistence that she was worse and by his counters that he had performed a perfect operation. When he spoke to her, he no longer addressed her by her first name. “Mrs. Allen,” he informed her, “I cannot do anything more for you. Your fusion is solid. Your X rays look fine. There is no reason to remove the hardware. You are just going to have to learn to live with some pain.” Tears welled in Jennifer’s eyes as she thought of the consequences of this judgment for herself and her family. She blinked them back and asked, “May I have something for the pain?” “Narcotics are not the answer here. I will refer you to a pain center. With biofeedback and injections I am sure you will improve over time.” The referral was made, and Jennifer now became a back cripple, dependent on narcotics, repeated back injections, electrical stimulators, psychological counseling, and pool therapy. She was able to raise her children, but her marriage became a hollow shell and gradually dissolved. She avoided sexual relations and focused her energy on two things: the children and managing her back pain. Her story, which is a common one, illustrates that surgery is sometimes better left undone. WHY HEALTH CARE IS SO EXPENSIVE 104 CH011.qxd 10/7/08 10:01 AM Page 104 Potentially or overtly unnecessary surgery comes...